This week is National Eating Disorder Awareness Week, so it feels fitting that this week's blog be about eating disorders. There are roughly 30 million people (10 million men and 20 million women) in the US who suffer from an eating disorder sometime during their lifetime. That's roughly 10%. The highest risk group are the 15-19 year olds, but those as young as 6 concerns over their body weight or shape.
What is an eating disorder? An eating disorder is an abnormal way of eating that leads to some sort of impairment and is usually related to concern over weight or body image. There are several types of eating disorders, all of which have slightly different characteristics.
Anorexia nervosa is one of the more common eating disorders. It is characterized by restriction of food intake, an intense fear of gaining weight, and abnormal body image (not feeling that they are underweight despite being underweight).
It is also the eating disorder with the highest risk of death. Due to starvation, the body's systems begin to shut down. One of the first signs of severe disease is the loss of menses (periods) in women. Other problems include muscle loss and weakness, changes in hair and skin, and changes in the heart muscle, which can lead to heart failure and death.
Anorexia is very much about control. These individuals will closely monitor how much they eat, may exercise excessively to burn additional calories, and tend to have other psychiatric disorders as well. Sometimes they are victims of abuse, and feel that anorexia is the only way that they can control their lives.
In some ways, anorexia has become glorified. There are "Pro-ana" websites out there, such as (TRIGGER WARNING) this one that promote anorexic behavior. There have been a number of celebrities with anorexia, including Karen Carpenter (died from complications of anorexia), Mary-Kate Olson, and Evanna Lynch (known for playing Luna Lovegood in the Harry Potter movies). Thankfully, most of these celebrities have sought treatment.
Bulimia nervosa is the other commonly known eating disorder, and is characterized by binging (eating large amounts of food), followed by behaviors to limit weight gain, such as purging (self-induced vomiting) or excessive exercise. These individuals are typically of a normal weight or slightly overweight (contrasted to those with anorexia, who are usually underweight). While anorexia is all about control, bulimia is more about loss of control, which leads to these binging episodes, followed by guilt, which leads to the behaviors to limit weight gain.
Bulimia comes with it's own host of health problems, most of which are associated with the purging: body chemistry imbalances (which can lead to heart failure and death), tooth decay, risk of tearing the esophagus, GI ulcers, and bad breath.
Note that not all people who purge suffer from bulimia; you can also be anorexic and purge.
Notable individuals who have suffered from bulimia include Demi Lovato, Katie Couric, and Lady Gaga.
There are other eating disorders as well, including Binge Eating disorder, which is characterized by binging without purging, and EDNOS or OSFED, which is a catch-all category for other forms of disordered eating that impair functioning.
The problem with all eating disorders, and the difficulty that lies in their treatment, is that we must all eat to survive, and those with an abnormal relationship with food have difficulty correcting it. It's not like smoking or drinking, where you can avoid the source of the problem with enough self-control. It truly takes a whole team to manage an eating disorder: a general physician to monitor overall health, a therapist to deal with the body image issues, and sometimes inpatient treatment to ensure that they don't kill themselves in the process of recovery (refeeding syndrome can be a problem in the treatment of severe anorexia).
If you or anyone you know has an eating disorder, seek help. NEDA has many resources available, and has a phone number and e-mail (located on the left sidebar below the menu) for anyone who needs help.
Sunday, February 23, 2014
Sunday, February 16, 2014
Having Kids Young: A Saga of Teen Pregnancy
Teen pregnancy. It was a fairly commonplace occurrence back in the 'old days', when 12 and 13 year olds were married off and made to have children. Now, it's something that will get you, in many ways, ostracized from normal society. Because there are many issues surrounding this topic, I will focus on them one at a time. There are also a number of charged political issues surrounding this topic, most notably the idea that teenagers can make their own medical decisions with regard to reproductive health, as well as the availability and use of contraception and abortion, particularly in the teenage population. I will do my best to limit my bias in those topics, but discussing them at all presents a bias on its own, so I can't make every piece completely unbiased.
For today, we'll examine the trends in teenage births (in the US).
The data that contains the most time is that of the National Vital Statistics Reports, covering the time period from 1940 to 2000. During this time period, we reached a peak of teen births in 1957, with a rate of 96.3 per 1,000 births. That means for every 1,000 babies more in 1957, roughly 96 of them were born to girls aged 15-19. Up until 1965 or so, we were still in the baby boom--the same population that has now grown up and is currently entering or in retirement. The fact that 1957 was the peak indicates that the desire to have children was present even in the teenagers of the era, who were too young to participate in the war itself.
A few more statistics that might be relevant: in 1950, the marriage rate in the US was 11.1%; in 1960, it was down to 8.5%. I don't have the numbers for the individual years, but the peak of births may very well have corresponded with a drop in marriage rates (fewer people getting married --> fewer people having children in future). Of course, that data does not break it down into teens vs. older women, so it may not be relevant at all. In addition, it should be noted that a 'soft peak' in the overall birth rate was seen in 1957 as well (see 1958 data, page 76), as 1958 began the decline of the overall birth rate as well.
After 1957, there was a steep decline in teen births, which was also associated with an increase in the percentage of these births to unmarried women. That is, prior to 1957, only 10% or so of births to women 15-19 were to unmarried women (so in 1957, 10 per 1000 babies was to an unwed teen). After 1957, as the birth rate decreased, the number of those to unmarried women increased. By the early 1980s, the teen birth rate was about 50 per 1,000 births, and half of them were to unmarried women (that is, roughly 25 per 1,000 babies born in the early 80s were to unwed teens).
In the late 1980s, we experienced an increase in the rate of teen births, which hit another peak in 1991 at 61.8 per 1000 births. Since 1991, though, teen birth rates have been declining, reaching an all-time low of 29.4 in 2012 (the most recent data available). Meanwhile, during that same period, overall births in the US have remained roughly the same, between 60 and 70 births per 1000 women since the mid-70s.
One more thing that is important to note; these statistics all refer to rates, not hard numbers. However, as the numbers from 2012 point out, we also experienced the lowest number of babies born to teen mothers in 2012 since the end of WWII. The year 1970 was the highest for the number of babies, at 644,708; for 2012, only 305,420 babies were born to girls aged 15-19.
However, note that all these statistics refer to live births by teenage mothers during the time period. It does not include abortions, miscarriages, or still-births. But those are a discussion for another blog.
So next time someone tells you that teen pregnancy is out of hand, it's worth it to refer to these statistics and point out that teen birth rates have been declining since 1991. The reason is likely multifactorial, and, once again, is a discussion for another blog.
Until next week!
For today, we'll examine the trends in teenage births (in the US).
The data that contains the most time is that of the National Vital Statistics Reports, covering the time period from 1940 to 2000. During this time period, we reached a peak of teen births in 1957, with a rate of 96.3 per 1,000 births. That means for every 1,000 babies more in 1957, roughly 96 of them were born to girls aged 15-19. Up until 1965 or so, we were still in the baby boom--the same population that has now grown up and is currently entering or in retirement. The fact that 1957 was the peak indicates that the desire to have children was present even in the teenagers of the era, who were too young to participate in the war itself.
A few more statistics that might be relevant: in 1950, the marriage rate in the US was 11.1%; in 1960, it was down to 8.5%. I don't have the numbers for the individual years, but the peak of births may very well have corresponded with a drop in marriage rates (fewer people getting married --> fewer people having children in future). Of course, that data does not break it down into teens vs. older women, so it may not be relevant at all. In addition, it should be noted that a 'soft peak' in the overall birth rate was seen in 1957 as well (see 1958 data, page 76), as 1958 began the decline of the overall birth rate as well.
After 1957, there was a steep decline in teen births, which was also associated with an increase in the percentage of these births to unmarried women. That is, prior to 1957, only 10% or so of births to women 15-19 were to unmarried women (so in 1957, 10 per 1000 babies was to an unwed teen). After 1957, as the birth rate decreased, the number of those to unmarried women increased. By the early 1980s, the teen birth rate was about 50 per 1,000 births, and half of them were to unmarried women (that is, roughly 25 per 1,000 babies born in the early 80s were to unwed teens).
In the late 1980s, we experienced an increase in the rate of teen births, which hit another peak in 1991 at 61.8 per 1000 births. Since 1991, though, teen birth rates have been declining, reaching an all-time low of 29.4 in 2012 (the most recent data available). Meanwhile, during that same period, overall births in the US have remained roughly the same, between 60 and 70 births per 1000 women since the mid-70s.
One more thing that is important to note; these statistics all refer to rates, not hard numbers. However, as the numbers from 2012 point out, we also experienced the lowest number of babies born to teen mothers in 2012 since the end of WWII. The year 1970 was the highest for the number of babies, at 644,708; for 2012, only 305,420 babies were born to girls aged 15-19.
However, note that all these statistics refer to live births by teenage mothers during the time period. It does not include abortions, miscarriages, or still-births. But those are a discussion for another blog.
So next time someone tells you that teen pregnancy is out of hand, it's worth it to refer to these statistics and point out that teen birth rates have been declining since 1991. The reason is likely multifactorial, and, once again, is a discussion for another blog.
Until next week!
Sunday, February 9, 2014
What is Death?
Death has become a very medicalized thing. Especially recently, with the stories of Marlise Munoz and Jahi McMath hitting the news. Due to patient privacy laws, we can't know everything that happened in those cases, but they point out important lessons for the world as a whole.
Within the medical field, there are two criteria for 'declaring' death: cardiac death and brain death. Cardiac death is exactly what you would expect: someone dies because their heart stops beating. If they are resuscitated, we generally don't consider them to have died, but I want to point out that resuscitation (with CPR and ACLS) is rather unlikely. As this study shows, less than 5% of people who receive effective CPR in the community are 'brought back'. This may vary a bit in the hospital setting, because response times tend to be a little faster, but it's still not very effective.
Brain death, or death by neurological criteria, is fairly recent in origin; in the past, if you became dead by neurologic criteria (say you were decapitated), you would stop breathing and eventually your heart would stop. With the introduction of ventilators, we are now able to keep the heart pumping even though the person is dead. Let me repeat that: the person is dead. They do not become dead when the ventilator is removed; they are dead. This seems to be a common misperception in the lay population, especially in the media (where you'll see that individuals are being 'kept alive' with ventilators), so I want to clear it up now. Before we go any further, I want to define a few more terms.
A coma is a state of extended unconsciousness, in which a person does not respond to things in the environment. A lot of people will talk about a 'medically induced coma.' This simply means that the person is being sedated, similar to being put to sleep for surgery, so that their bodies can heal from whatever injury they had. Medically induced comas can be reversed by simply stopping the sedation medications. Spontaneous coma, usually caused by lack of oxygen to the brain, is potentially reversible—the longer you are in a coma, the less likely you are to return to your normal function. If the person in a coma does not regain consciousness within a period of time, usually a month, they are said to be in a persistent vegetative state (PVS). These people retain function of their brainstems, but do not have any higher brain activity—they do not think, interact with the world around them, etc. They are a body with reflexes.
In order to be considered brain dead (or dead by neurological criteria), you have to lose all brainstem function. The brainstem is the part of the brain that connects the brain to the rest of the body via the spinal cord. The things controlled here are things we don't need higher brain function for: breathing, controlling the speed of our heart, blinking, gagging, etc. The tests that must be run prior to diagnosing death by neurological criteria are: known cause of irreversible lack of brain function; cranial nerve function (pupils that do not move, lack of gag and blinking reflex, no withdrawal from painful stimuli); and inability to breathe spontaneously. This last test is done by turning off the ventilator for 10 minutes, and death is declared at the end of the 10 minutes.
If all these criteria are met, the person is dead. They have absolutely no hope of recovering. They are not in a coma, they are not in a vegetative state; they are dead. They are a shell of a body, if you will. Note, they will still have spinal cord reflexes, so if you bang on their knees, their legs might jerk, but those are not signs of brainstem function. Their heart is only beating because air is being pumping into their lungs and their heart muscle has not yet died. As such, these people are good candidates for organ transplant, because their organs are still getting oxygen because their hearts are still beating. Someone who died because their heart stopped is on a much shorter time scale, and many of the organs may not be functional long enough to be of use.
As a random aside, I recently watched a lecture in which the speaker was talking about the ineffectiveness of ACLS, which is used in the hospital setting when someone's heart stops. He made the point that failed treatment has the exact same outcome as no treatment at all... death. The person is still dead. The difference is, of course, hundreds of dollars of expensive medical treatment and the virtual destruction of the body in the process. Go gentle into that good night indeed. But for the most part, we are willing to pay this cost for the handful of people for whom this treatment is successful.
These are the medical ways that we define death, and most everyone accepts them. Different religions can have varying opinions of what death is. Some say it's when the soul leaves the body. Others say it's when a person stops breathing. All of these, of course, make it difficult to correlate medical death with 'death' according to these religions. That makes for some interesting issues surrounding the end of life. But that's a topic for another blog.
If you take nothing away from this blog, please, please, talk to your families about your wishes if you end up in an accident. It's really difficult to cover all the possible scenarios, but if you fill out an advanced directive before all this happens, then you can save your family a world of hurt trying to make these decisions for you. If you don't want to remain in a persistent vegetative state, you have the right to deny medical treatment in those circumstances (which may include ventilator support or feeding tubes), but the only way your family will know that that's what you want is if you tell them.
Within the medical field, there are two criteria for 'declaring' death: cardiac death and brain death. Cardiac death is exactly what you would expect: someone dies because their heart stops beating. If they are resuscitated, we generally don't consider them to have died, but I want to point out that resuscitation (with CPR and ACLS) is rather unlikely. As this study shows, less than 5% of people who receive effective CPR in the community are 'brought back'. This may vary a bit in the hospital setting, because response times tend to be a little faster, but it's still not very effective.
Brain death, or death by neurological criteria, is fairly recent in origin; in the past, if you became dead by neurologic criteria (say you were decapitated), you would stop breathing and eventually your heart would stop. With the introduction of ventilators, we are now able to keep the heart pumping even though the person is dead. Let me repeat that: the person is dead. They do not become dead when the ventilator is removed; they are dead. This seems to be a common misperception in the lay population, especially in the media (where you'll see that individuals are being 'kept alive' with ventilators), so I want to clear it up now. Before we go any further, I want to define a few more terms.
A coma is a state of extended unconsciousness, in which a person does not respond to things in the environment. A lot of people will talk about a 'medically induced coma.' This simply means that the person is being sedated, similar to being put to sleep for surgery, so that their bodies can heal from whatever injury they had. Medically induced comas can be reversed by simply stopping the sedation medications. Spontaneous coma, usually caused by lack of oxygen to the brain, is potentially reversible—the longer you are in a coma, the less likely you are to return to your normal function. If the person in a coma does not regain consciousness within a period of time, usually a month, they are said to be in a persistent vegetative state (PVS). These people retain function of their brainstems, but do not have any higher brain activity—they do not think, interact with the world around them, etc. They are a body with reflexes.
In order to be considered brain dead (or dead by neurological criteria), you have to lose all brainstem function. The brainstem is the part of the brain that connects the brain to the rest of the body via the spinal cord. The things controlled here are things we don't need higher brain function for: breathing, controlling the speed of our heart, blinking, gagging, etc. The tests that must be run prior to diagnosing death by neurological criteria are: known cause of irreversible lack of brain function; cranial nerve function (pupils that do not move, lack of gag and blinking reflex, no withdrawal from painful stimuli); and inability to breathe spontaneously. This last test is done by turning off the ventilator for 10 minutes, and death is declared at the end of the 10 minutes.
If all these criteria are met, the person is dead. They have absolutely no hope of recovering. They are not in a coma, they are not in a vegetative state; they are dead. They are a shell of a body, if you will. Note, they will still have spinal cord reflexes, so if you bang on their knees, their legs might jerk, but those are not signs of brainstem function. Their heart is only beating because air is being pumping into their lungs and their heart muscle has not yet died. As such, these people are good candidates for organ transplant, because their organs are still getting oxygen because their hearts are still beating. Someone who died because their heart stopped is on a much shorter time scale, and many of the organs may not be functional long enough to be of use.
As a random aside, I recently watched a lecture in which the speaker was talking about the ineffectiveness of ACLS, which is used in the hospital setting when someone's heart stops. He made the point that failed treatment has the exact same outcome as no treatment at all... death. The person is still dead. The difference is, of course, hundreds of dollars of expensive medical treatment and the virtual destruction of the body in the process. Go gentle into that good night indeed. But for the most part, we are willing to pay this cost for the handful of people for whom this treatment is successful.
These are the medical ways that we define death, and most everyone accepts them. Different religions can have varying opinions of what death is. Some say it's when the soul leaves the body. Others say it's when a person stops breathing. All of these, of course, make it difficult to correlate medical death with 'death' according to these religions. That makes for some interesting issues surrounding the end of life. But that's a topic for another blog.
If you take nothing away from this blog, please, please, talk to your families about your wishes if you end up in an accident. It's really difficult to cover all the possible scenarios, but if you fill out an advanced directive before all this happens, then you can save your family a world of hurt trying to make these decisions for you. If you don't want to remain in a persistent vegetative state, you have the right to deny medical treatment in those circumstances (which may include ventilator support or feeding tubes), but the only way your family will know that that's what you want is if you tell them.
Sunday, February 2, 2014
A Doctor's Education
Before I spend time writing up blogs on various topics in medicine, I want to address something that seems to be ignored by the general public: the amount of education it requires to become a physician. I am not doing this to flaunt my own efforts, but my own family has had difficulty grasping the path to becoming a practicing physician. It's a long process, and a lot of people feel that physicians make too much--but really, for the majority of physicians, the debt we accrue is sufficiently high that we need a high salary to make up for it. Furthermore, I want to emphasize that we are continually tested, so that the practices that we do weren't just picked out of thin air.
So, without further ado, the path to becoming a physician:
1. College
You need a bachelor's degree prior to entering medical school in the US. There are a few, rare exceptions, but we're talking 1-2 people out of the thousands of medical students each year. It doesn't particularly matter what you major in, just that you fulfill some basic requirements. The requirements are actually changing a bit from when I applied 4 years ago, but generally include 4 years (8 semesters) of science courses, including Biology, Chemistry, Organic Chemistry, and Physics, with labs; some sort of English or writing course; some sort of math (generally Statistics and/or Calculus); some sort of humanities course (Psychology, Sociology, etc); and occasionally some upper level science courses such as Biochemistry.
Prior to applying to medical school, you need to take the Medical College Admissions Test (MCAT). It's similar to the ACT or the SAT, except that it focuses on reading comprehension and basic understanding of science concepts. It is scored on a scale of 3-45, with most people scoring somewhere between 25 and 35.
Medical school applications are a beast, but include filling out a central application with every college course you've ever taken, sending your MCAT score, and sending in letters of recommendation from professors, supervisors, etc. The application cycle lasts roughly 1 year; the application opens for submission in June for matriculation the following August. Each school requires a secondary application (and associated fee) with a variable number of essays. You are then selected to interview and must travel to the school to interview.
2. Medical School
Assuming you get through the admissions process, the next step is medical school. It is 4 years, though some schools are piloting 3 year programs, broken up into 2 parts: basic science, and clinical work.
The basic science part is classroom based, and includes courses on everything you need to know about the human body, from anatomy and physiology, to pathology and radiology. Generally, students are also learning the basics about interviewing and examining patients during this time as well. This portion is generally 2 years long, though some schools have made it as short as 1 year and many schools have moved to 18 month curriculums.
For most students, after you complete the basic science instruction, you take the first part of the United States Medical Licensing Exam (USMLE), affectionately referred to as 'Step 1'. This is an 8-hour test that covers all the material you learn during this first portion of medical school. It is scored on a 3-point scale, with a passing score of around 190. In theory, there is no highest score you can achieve, but it is exceedingly rare to find someone scoring more than 270. The national average is currently around 223. This score can determine which specialty you ultimately practice, as lower scores can preclude competitive specialties such as Dermatology or Radiology.
Then, students enter the clinical portion of medical school. Here, they work in a hospital or outpatient clinic with supervising physicians. They interview patients, try to figure out what is wrong with them, and follow them through their hospital stay. This is generally broken into 'clerkships' of the major specialties: Internal Medicine, Pediatrics, Surgery, OB/GYN, Psychiatry, etc. Following this year, students take Step 2 of the USMLE, which is broken into a 9-hour written exam focused on the treatment of a variety of diseases and conditions, and a 8-hour practical exam, which is focused on the ability to communicate with patients (using actors mimicking a variety of medical illnesses).
Finally, students have the opportunity to explore other interests in medicine through electives during their fourth and final year in medical school. Electives are generally broad, and can include travelling overseas, or working in specialties not typically experienced during third year (Radiology, Dermatology, Subspecialties of Internal Medicine and Pediatrics, etc). During this time, students make a decision for what they want to pursue for their career, and apply for residency positions. Similar to medical school applications, residency applications require letters of recommendation, course grades, and interviews.
The residency interview season culminates in Match Day. Applicants rank all the programs they interviewed at and are interested in, and programs do the same with the students they interviewed. A computer goes through both sets of lists, and comes up with a 'match' based on those rankings. Students find out where they will be spending the next portion of their training on Match Day, which is traditionally the third Friday in March. Following Match Day, students finish graduation requirements, and graduate with their degrees in May.
3. Residency
Even having an MD (Medical Doctorate) or DO (Doctorate of Osteopathic Medicine) does not qualify you to practice medicine. In order to get a license to practice, you must complete at least 1 year of residency; even then, most insurance companies won't pay you if you have not completed at least 3. Residencies range in length; general Internal Medicine, Pediatrics, and Family Medicine are 3 years, while General Surgery is at least 5 years. They focus on skills needed to be a competent physician, and include both inpatient and outpatient care. These individuals typically work 60-80 hours per week (that's 1.5-2 full time jobs), and make about $50,000 for their salary (it increases slightly each year). That's $13-$17 per hour, saving lives.
During your residency, generally in the first 1-2 years, you take Step 3 of the USMLE. Passing this makes you eligible for a license to practice. Upon the conclusion of residency, you take another exam to become Board Certified in your specialty.
4. Fellowship
In the event someone doesn't want to do general medicine within their field, they can choose to undergo further training through fellowship. For instance, those who specialize in Pediatric Gastroenterology first underwent a residency in General Pediatrics, then did a fellowship in Pediatric Gastroenterology. Those in fellowship are paid on the same graduated scale as residents, which means they typically only make $5,000-$10,000 more per year than a first year resident.
In summary, a general family medicine, pediatric, or internal medicine physician (those who provide primary care), spend 4 years in college, 4 years in medical school, and 3 years in residency, minimum. The trend lately is to take time off between college and medical school, which means these people are easily into their 30s when they are finally permitted to practice. And given that medical school alone comes with an average debt around $150,000, they certainly put in the effort to make the salary they do.
So, without further ado, the path to becoming a physician:
1. College
You need a bachelor's degree prior to entering medical school in the US. There are a few, rare exceptions, but we're talking 1-2 people out of the thousands of medical students each year. It doesn't particularly matter what you major in, just that you fulfill some basic requirements. The requirements are actually changing a bit from when I applied 4 years ago, but generally include 4 years (8 semesters) of science courses, including Biology, Chemistry, Organic Chemistry, and Physics, with labs; some sort of English or writing course; some sort of math (generally Statistics and/or Calculus); some sort of humanities course (Psychology, Sociology, etc); and occasionally some upper level science courses such as Biochemistry.
Prior to applying to medical school, you need to take the Medical College Admissions Test (MCAT). It's similar to the ACT or the SAT, except that it focuses on reading comprehension and basic understanding of science concepts. It is scored on a scale of 3-45, with most people scoring somewhere between 25 and 35.
Medical school applications are a beast, but include filling out a central application with every college course you've ever taken, sending your MCAT score, and sending in letters of recommendation from professors, supervisors, etc. The application cycle lasts roughly 1 year; the application opens for submission in June for matriculation the following August. Each school requires a secondary application (and associated fee) with a variable number of essays. You are then selected to interview and must travel to the school to interview.
2. Medical School
Assuming you get through the admissions process, the next step is medical school. It is 4 years, though some schools are piloting 3 year programs, broken up into 2 parts: basic science, and clinical work.
The basic science part is classroom based, and includes courses on everything you need to know about the human body, from anatomy and physiology, to pathology and radiology. Generally, students are also learning the basics about interviewing and examining patients during this time as well. This portion is generally 2 years long, though some schools have made it as short as 1 year and many schools have moved to 18 month curriculums.
For most students, after you complete the basic science instruction, you take the first part of the United States Medical Licensing Exam (USMLE), affectionately referred to as 'Step 1'. This is an 8-hour test that covers all the material you learn during this first portion of medical school. It is scored on a 3-point scale, with a passing score of around 190. In theory, there is no highest score you can achieve, but it is exceedingly rare to find someone scoring more than 270. The national average is currently around 223. This score can determine which specialty you ultimately practice, as lower scores can preclude competitive specialties such as Dermatology or Radiology.
Then, students enter the clinical portion of medical school. Here, they work in a hospital or outpatient clinic with supervising physicians. They interview patients, try to figure out what is wrong with them, and follow them through their hospital stay. This is generally broken into 'clerkships' of the major specialties: Internal Medicine, Pediatrics, Surgery, OB/GYN, Psychiatry, etc. Following this year, students take Step 2 of the USMLE, which is broken into a 9-hour written exam focused on the treatment of a variety of diseases and conditions, and a 8-hour practical exam, which is focused on the ability to communicate with patients (using actors mimicking a variety of medical illnesses).
Finally, students have the opportunity to explore other interests in medicine through electives during their fourth and final year in medical school. Electives are generally broad, and can include travelling overseas, or working in specialties not typically experienced during third year (Radiology, Dermatology, Subspecialties of Internal Medicine and Pediatrics, etc). During this time, students make a decision for what they want to pursue for their career, and apply for residency positions. Similar to medical school applications, residency applications require letters of recommendation, course grades, and interviews.
The residency interview season culminates in Match Day. Applicants rank all the programs they interviewed at and are interested in, and programs do the same with the students they interviewed. A computer goes through both sets of lists, and comes up with a 'match' based on those rankings. Students find out where they will be spending the next portion of their training on Match Day, which is traditionally the third Friday in March. Following Match Day, students finish graduation requirements, and graduate with their degrees in May.
3. Residency
Even having an MD (Medical Doctorate) or DO (Doctorate of Osteopathic Medicine) does not qualify you to practice medicine. In order to get a license to practice, you must complete at least 1 year of residency; even then, most insurance companies won't pay you if you have not completed at least 3. Residencies range in length; general Internal Medicine, Pediatrics, and Family Medicine are 3 years, while General Surgery is at least 5 years. They focus on skills needed to be a competent physician, and include both inpatient and outpatient care. These individuals typically work 60-80 hours per week (that's 1.5-2 full time jobs), and make about $50,000 for their salary (it increases slightly each year). That's $13-$17 per hour, saving lives.
During your residency, generally in the first 1-2 years, you take Step 3 of the USMLE. Passing this makes you eligible for a license to practice. Upon the conclusion of residency, you take another exam to become Board Certified in your specialty.
4. Fellowship
In the event someone doesn't want to do general medicine within their field, they can choose to undergo further training through fellowship. For instance, those who specialize in Pediatric Gastroenterology first underwent a residency in General Pediatrics, then did a fellowship in Pediatric Gastroenterology. Those in fellowship are paid on the same graduated scale as residents, which means they typically only make $5,000-$10,000 more per year than a first year resident.
In summary, a general family medicine, pediatric, or internal medicine physician (those who provide primary care), spend 4 years in college, 4 years in medical school, and 3 years in residency, minimum. The trend lately is to take time off between college and medical school, which means these people are easily into their 30s when they are finally permitted to practice. And given that medical school alone comes with an average debt around $150,000, they certainly put in the effort to make the salary they do.
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